Driving Primary Healthcare Transformations Across a Health System: What Does It Take to Get There?
ACCESS Health International and the Bill & Melinda Gates Foundation convened a day long consultation on primary healthcare in India titled, Driving Primary Healthcare Transformations Across a Health System: What Does It Take to Get There? The objective of the consultation was to engage with experts on pertinent themes related to primary care, including financing and provider payments, systems for accountability, and the integration of care between primary, secondary, and tertiary levels. The consultation was also used to solicit feedback on a primary healthcare model that we have designed for potential implementation in different Indian states. Nearly forty participants joined the meeting, representing entrepenuers, investors, development partners, and policymakers. This blog post offers a summary of the rich and influential discussion.
We set the context for the meeting by outlining the key challenges in the primary healthcare system in India. It is a fragmented delivery system, with public and private providers operating in distinct spheres; disease control programs organized in vertical silos; and primary, secondary, and tertiary levels of care fractured from one other. Like in many other countries, healthcare delivery in India is organized from tertiary care to primary care, rather than the other way around. Ultimately, this arrangement compromises the health seeking experience and outcomes for communities. The challenge of the day is to redefine the delivery structures in the health system to serve communities better.
For over a year, we have worked with the Gates Foundation and state governments to design a transformative primary healthcare model. Our intention is to create a prototype model that can be customized for different states and local contexts. The features that distinguish this model from the status quo include universal enrollment and proactive management of population health; provision of comprehensive primary care services by a multiprofessional team of health workers; introduction of capitation and performance based financing to shift focus from inputs to outcomes; and the creation of autonomous and accountable structures to govern, finance, and provide health services. Perhaps the most distinguishing aspect of the model is that it engages a nongovernmental agency (the system manager) that will operate under government oversight and be held accountable for the professional management of primary healthcare services for a defined geography. While we expect variation in the model according to local priorities and the appetite for change among state governments, a unifying vision for this work is to increase population access to high quality healthcare, reduce out of pocket payments, and improve health outcomes.
Many important questions and debates were raised over the course of the consultation. The most salient takeaways are summarized below.
Ensure clear and measurable benefits of the program. Participants acknowledged the importance of ensuring that the payoff from the model is tangible and clear, and that it justifies the transformation. The most immediate political reward will be customer satisfaction. The model should therefore aim to change fundamentally the care seeking experience for communities. To achieve this change will entail raising awareness, delivering high quality services, and monitoring and acting on customer feedback. Continuous program communication will be a critical component to ensure customer satisfaction. This means that the system manager should creatively engage communities and raise awareness, and state governments should promote the program and make primary care an important and visible part of their manifesto.
Structure the contract as a risk sharing partnership. Many public private partnerships are designed as outsourcing contracts rather than real partnerships. A real partnership should have shared risks and responsibilities, and a common long term vision. In our model, the system manager will share risk and manage the health of the population through a capitation based payment structure. However, the risk will be limited and capped, given the unknown disease burden, use of care, and cost of delivery. Besides receiving a base per capita payment, the system manager will be compensated for achieving high quality outcomes, that is, for demonstrating value rather than volume alone. The terms of reference for any system manager should clearly outline the key performance indicators and expected outcomes and should give room for flexibility and course correction during the contract. This innovative contract structure is intended to offer a template for testing and learning and to build the market for improved provider purchasing. Participants underscored the importance of developing the purchasing capacity of relevent government departments and of ensuring that payments are assured and on time.
Create a roadmap to integrate with secondary and tertiary care. Ideally, primary care should be conceived as an integrated component with secondary and tertiary care, from an access, quality, and cost point of view. Primary care can also be made more attractive to politicians when it is bundled with secondary and tertiary care. A few states in India are starting to discuss experiments that link primary care with insurance, though there is little progress on the ground. Participants at the meeting recommended that we influence the design of the next wave of social health insurance in the states where we work. The first step toward this would entail adapting the information technology platform so it is integrated across levels of care, and can, for example, support a common electronic patient record. A second consideration is to align the population base for primary and secondary coverage. We intend to ensure universal access to primary care, though many insurance programs are reserved for below poverty line populations. Any step toward integration will require consideration of the additional funds needed to cover a wider population base. In the longer term, our vision is to integrate management and funding across levels of care, giving incentive to the system managers to focus on prevention, early diagnosis, effective treatment, and a consequent reduction in hospitalization.
Develop a plan to reach scale and to exit. We received a clear message on the need to carefully review our plan for scale up and exit. Participants recommended that as part of the design of this model, we consider building the capacity of state governments to take over from the system manager. The root hypothesis is that it is unrealistic for the private sector to assume full responsibility for provisioning of care in the public system. We operate in a mixed market system and have an opportunity to develop a road map to improve the structure and interrelationship between the public and private sectors. It was suggested that we create a parallel experiment to build the capacity of state governments to strengthen their provision of primary care services. Over time, we will have a repository of experience on the comparative strengths of the public and private sectors in different states and the evidence to inform the growth of a high performing, coordinated, and regulated mixed healthcare system.
The meeting concluded with a round of consensus and encouragement to move forward with our bold experiments. With this, we are excited to continue our work and to put into practice all the sound advice we have received.